Client Intake Form

First name*

Last name*

Email*

Phone*

Birthday

Day

Month

Year

Occupation*

Emergency contact name and phone*

Services you're engaging with*

Holistic Counselling

Reiki Energy Healing

Pellowah Healing

Holistic Beauty Therapy/Skin Care

Combination session

Health and Wellbeing (Confidential)

Are there any physical or mental health conditions I should be aware of?*

Yes

Do you have any skin allergies or sensitivities (especially skin – related)?*

Yes

Are you currently under the care of a medical or mental health professional?*

Yes

If yes, please specify

Are you currently taking any form of medications?*

Yes

If yes, please specify

What specific areas would you like to explore during your holistic therapy?

Confidentiality & Boundaries Acknowledgement

By submitting this form, you agree and understand:

Sessions are held in a confi dential, respectful, and non -judgmental space.
Services provided are complementary in nature and not a substitute for medical or psychological treatment.
You take full responsibility for your own health and well-being during and after the session.
You may discontinue services at any time.
I reserve the right to reschedule, refuse, or terminate a session if boundaries are not respected

I understand and agree to the above:*

Yes

Consent to Treatment

I Consent to receiving holistic services (counselling, reiki, and/or beauty therapy) from (currently Torquay Beauty Therapy), and I understand the nature and scope of these services.

I confirm that all information I’ve provided is honest and accurate to the best of my knowledge.

I am over 18 years of age or have guardian consent.

Signature*

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Date*

Day

Month

Year

0412 195 113

The Healing Nest Torquay

info@thehealingnesttorquay.com.au

Zeally Sands, Torquay

Code of Ethics

Terms & Conditions - Payment policy

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